tci ED Coding & Reimbursement Alert - 2003 Issue 1

Reader Question: The 1997 Guidelines Can Prove Helpful

Question: A patient came to the ED with a foreign body in his eye. The emergency physician documented fluorescein dye, Wood's lamp and slit lamp exam. Documentation also includes several attempts to remove the foreign body with no success. The physical exam showed a severely infected sclera as well as an abrasion. The patient was discharged with two RX and sent to the eye-care center where the foreign body was removed. Does the physical exam support a level-three E/M code for Medicare even though no other body areas or organ systems were examined? Is the extensive exam of the...

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